Automated Insulin Delivery (AID) System Study Day for Type 1 Diabetes

Greetings!

You’re about to embark on an educational adventure into the realm of Automated Insulin Delivery (AID) Systems, also known as Hybrid Closed Loop (HCL) Systems.

After intense learning, trial and error, publications, and guiding hundreds of children and young people living with type 1 diabetes onto AID systems at Birmingham Children’s Hospital, we created a “top notch” study day.

We delivered the programme to our team; it went down a storm, so we are sharing it.

The content has a paediatric focus. However, 90% of the material translates perfectly to adults. Things missing are pregnancy and managing complications such as gastroparesis. We don’t see these patients, so we don’t pretend to know what we are doing!

You can download all the presentations, videos, PowerPoints, guides, tools, leaflets, etc from this Google Drive.

We have removed BCH logos and service details from all PDF materials and permit you to use them as you wish. You will need to purchase an Adobe Acrobat Pro license to edit the PDFs.

Journey Through the Study Day

The study day is structured into three segments:

The AID Therapy Landscape (this can be skipped by those wanting AID System specifics. However, important context and service change strategies will be missed)
- We’ll commence with a brief exploration of the AID therapy evidence base. We then discuss equitable onboarding and strategies for pivotal service changes to ensure a seamless, high-quality service.
A Deep Dive into Four AID Systems
- Next, we’ll plunge into the specifics of the four AID systems available in the UK: MinMed 780G System, Omnipod 5 System, t:slim x2 with Control-IQ, and CamAPS FX. Prepare for case studies that challenge the translation of theoretical knowledge into clinical prowess.
Insider Tips and Tricks
- Finally, prepare for a treat with top tips and tricks from globally acclaimed speakers. Their insights cover supporting young children and exercise enthusiasts, the art of delivering impactful nutritional messages, and how to manage a night on the booze.

Active learning is the heart of this experience. This booklet is a learning companion. Completing the program as a team helps unify the approach. It can be done all in one sitting or bite-size chunks.

Scribble down key learnings, implementation plans, and reflections.

Our top insights are sprinkled at the end of each section for cross reference.

It’s crucial to remember that technology and evidence evolve, but the principles communicated on the study day (March 2024) remain timeless.

However, this study day isn’t designed to be prescriptive. We are sharing our service journey and what has worked wonders for us.

Take what you need and disregard the rest.

Four Stages of Learning

Where are you at?

Unconscious Incompetence – You’re in the dark about what you don’t know. You may be at this stage if AID therapy is new to you. Some of the material may take some time to sink in. Stick with it!
Conscious Incompetence – You know what you don’t know and are eager to learn. Most will start here and gain a lot from the programme.
Conscious Competence is the post-study day goal, where application brings knowledge. A few will already be here. If you are, please help guide the others while picking up a few insights. Furthermore, you are well-placed to be skeptical, so go for it and let us know what needs adapting.
Unconscious Competence – Mastery through persistent learning and experimentation over many years. Rarified air for the likes of Francesca Annan, Dessi Zahareiva, and Elizabeth Jelleryd (the globally acclaimed speakers you will hear from at the end). Hardly anyone sits here. If you do, please help the others. Furthermore, you should provide critical feedback on the contents – this is very much welcomed!

Section 1: The World of AID Therapy and How to Onboard Equitably

Session 1: The Three W’s

Why AID Therapy: A dive into the daily variability of insulin requirements and how AID Systems meet the challenge.
Where We Were: Our honest and hard-to-swallow review of inequitable allocation of AID Systems up to 2023.
Where We’re Going: Looking ahead to 2024 to ensure equitable onboarding to meet the NICE TA943 for HCL

Top Three Learnings:

The flexibility of AID systems meets varying insulin needs, and the variability from day to day and across the day makes you realise the challenge of managing type 1 diabetes.
Self-assessment to determine if AID onboarding is equitable is the essential first step. Stop pretending and review the data to find out. It might be painful, but pain brings about change!
The exciting potential of NICE TA 943 for unprecedented AID therapy access. The rate-limiting step is the onboarding cadence of Diabetes Teams. There is a need to think differently and embrace digital technologies to speed up onboarding equitably.

Session 2: The Three C’s

Capacity Creation: Strategies to make room to prioritise AID onboarding.
Creation of Pathways: How we switched from face-to-face-only onboarding to a versatile virtual model.
Checking the Results: Insights from our audit.

Top Three Learnings:

AID therapy: A high-value activity that may require deprioritising others. Moreover, the efficacy of a hybrid virtual programme in capacity creation is to halve educator time and increase onboarding cadence five-fold.
The step-by-step teaching guides, Survive and Thrive guides, and school care plans we have created serve as a template to save time.
Starting settings calculators and AID download assessment tools should be treated as idiots. They make suggestions based on the average person’s insulin sensitivity. The recommendations should be taken with a pinch of salt, and clinical judgment should reign supreme. Finally, embrace a mindset of continuous improvement through auditing.

Here are all the resources with the associated evidence-based base for our programme. Reading the full story of our service transformation may be valuable for those teams wanting to meet the NICE TA 943 challenge.

Resources	Description
Step-by-step teaching guides	The educational content was developed using methods outlined in the ATTD consensus on AID technologies (1) and the UK Diabetes Technology Network’s Best Practice Guidelines (2). These resources cover a range of topics including AID expectations, hypoglycaemia and hyperglycaemia management, infusion site care, nutrition advice, CGM management, and analysis of downloaded data. Exercise management advice was based on the ISPAD 2022 Exercise guidelines (3) and a detailed practical guide (4). The materials also encompass GAME-SET-MATCH strategies for optimising TIR (5–7) and a Mealtime Insulin Guide for T1D. To cater to different learning styles, we included manufacturers’ PowerPoint presentations, YouTube videos, and various explanatory tools. Additionally, we produced brief educational videos (5-10 minutes) to ensure clarity and consistency in messaging, which are accessible on www.screencast-o-matic.com at an annual cost of approximately £100. Each AID System (780G, CAMS, CIQ, and OP5) received a custom teaching guide, reviewed by the respective manufacturer’s education team. The Diabetes Team and CYP participating in the education sessions continually evaluated and enhanced these materials over a six-month period. Download links: 780G OP5 CIQ CAMS (Under construction)
Survive and Thrive guides	A crucial tool for CYP was the customised “Survive and Thrive” PDF guide, individually created for each AID system through JavaScript coding and Adobe Acrobat DC (annual cost of ~£180). This interactive guide generates a personalised hypoglycaemia treatment plan (5,6) and calculates carbohydrate needs for exercise based on the user’s name and weight, using ISPAD’s algorithms (3). It includes QR codes that link to essential short videos (5-10 minutes) covering key management techniques. The “Survive” section of the guide focuses on managing hypoglycaemia and hyperglycaemia, obtaining accurate CGM readings, infusion site management, and essential kit items to carry. The “Thrive” section details crucial nutritional and exercise management strategies, incorporating GAME-SET-MATCH approaches for optimising TIR (5,6) and a Mealtime Insulin Guide for Type 1 Diabetes (T1D). Each AID system, including 780G, CAMS, CIQ, and OP5, has a dedicated version of this guide, which has been reviewed by the education team of each system’s manufacturer. The Diabetes Team, along with the CYP participating in the education sessions, continuously reviewed and improved these materials over a period of six months. Download links: 780G OP5 CIQ CAMS
Interactive School Careplans	Similar to the “Survive and Thrive” guide, we transformed AID school care plans into interactive PDFs with embedded videos, requiring an 80% competency score for completion, thus reducing the need for direct teaching by healthcare professionals (8). Download links: 780G OP5 CIQ CAMS with Dana CAMS with Ypso
AID starting settings calculator	We adapted the Automated Insulin Delivery (AID) starting dose calculator originally created by the University College of London’s Diabetes Team. This calculator is grounded in the insulin setting guidelines proposed by the ISPAD 2022 guidelines (9) and incorporates research on paediatric bolus calculator settings (10). Our enhancements to the calculator were informed by the ATTD consensus recommendations, allowing it to produce tailored initial settings for various AID systems that support smooth onboarding. Download links: AID Starting Settings Calculator Algorithms behind the calculator
AID download assessment tool	This starting settings calculator led to the development of a download assessment clinical tool. We integrated the calculator’s algorithms with our understanding of factors influencing automated mode and manual mode adjustments in AID systems (1). This tool provides users with insights into which settings affect each mode of the AID system. It also offers tailored suggestions for optimising glucose control. These suggestions are based on several factors: current TIR, total daily insulin dose, desired percentage of basal insulin, and the specific AID system in use. The tool thus serves as an efficient guide for clinicians in supporting CYP make effective adjustments to their AID systems. Download links: Download Assessment PDF tool
Google Forms	We developed Google Forms for AID system selection and pre-initiation education, incorporating teaching guide materials, current insulin settings, setup guides, links to AID simulator applications, and an automated quiz with an 80% pass requirement for progression to onboarding. The forms also facilitated efficient organisation of onboarding sessions. Download links: AID System Selection Google Form Prototype , 780G Pre-AID Education Google Form Prototype OP5 Pre-AID Education Google Form Prototype CIQ Pre-AID Education Google Form Prototype CamAPS FX (under construction)

Session 3: AID System Selection

Thanks to Anne-Marie Frohock from Oxford for helping to put the slides together.

We made slight mistake! Control-IQ predicts 30 min into the future, not 10 as is suggested!

Top Three Learnings:

Each AID system is like a unique supercar; suitability varies per individual.
Online resources such as Google or Teams forms are practical tools for system selection and pre-AID education.
Guiding rather than dictating AID system choices.

Here is a guide on choosing an AID System for people with type 1 diabetes.

Section 2: In-Depth Analysis of AID Systems

Session 1: Control-IQ

You will need the AID Tool and the Survive and Thrive Guide for T-Slim and download the T:Simulator for Apple or Android.

Understanding how it works and how to assess downloads
Case Study Analysis and AID Tool Introduction
Again, Control-IQ predicts 30 min into the future, not 10 as is suggested!

This next video is our approach to creating and assessing a Control-IQ download. This is not how to do it, merely how we do it. Take what you need and disregard the rest.

Now it’s your turn.

Case Study 1 and the AID Tool for Case Study 1. Work through and bounce ideas off your colleagues.

Case Study 2, the AID Tool for Case Study 2. Work through and bounce ideas off your colleagues.

Here are our thoughts on the two t:slim case studies. Don’t be lazy and look at what we thought first! Do the work, then cross reference. I bet you identify loads of things we missed!

Top Three Learnings:

Importance of keeping basal rates and correction factors updated. Nothing is wrong with one flat basal rate to make updating simple for most people. Then, use the correction factor to optimise the algorithm. However, those with the dawn or dusk phenomenon may need different basal rates.
The correction factor is THE most important setting to optimise for Control-IQ to get more time in range.
Control-IQ has ultimate flexibility in meeting the diverse needs of Type 1 Diabetes patients. However, “With great power comes great responsibility!”. For children and young people (not so much adults), Control-IQ requires frequent updates to basal rates and correction factors by the user or the diabetes team to keep the setting optimised.

Session 2: Omnipod 5

You will need the AID Tool and the Survive and Thrive Guide for Omnipod 5, and the Simulator for Apple or Android.

The algorithm in view and how to work through a download
Case Study Exploration and AID Tool Usage

This next video is our approach to creating and assessing an Omnipod 5 download. This is not prescriptive, merely a guide.

Now it’s your turn.

Case Study 1, the AID Tool for Case Study 1 , work through and bounce ideas off your colleagues.

Case Study 2, the AID Tool for Case Study 2, Work through and bounce ideas off your colleagues.

Here are our thoughts on the two Omnipod 5 case studies . Don’t cheat by looking before assessing! Give it a go, then cross reference. I bet you spot a lot we missed!

Top Three Learnings:

Tailoring target levels at different times of the day enables the algorithm to match individual insulin requirements.
Enhancing connectivity between Pod and sensor – close line of sight, especially for those who swim a lot.
Utilising activity mode for exercise and alcohol is essential as the algorithm’s aggressiveness is halved.

Session 3: 780G

You will need the AID Tool and the Survive and Thrive Guide for 780G, and the simulator.

System Mechanics and Assessment Strategies
Interactive Case Studies and AID Tool Deployment

The next video is our approach to creating and assessing a 780G download. This is not prescriptive, merely a guide.

Now it’s your turn.

Case Study 1, the AID Tool for Case Study 1 , work through and bounce ideas off your colleagues.

Case Study 2, the AID Tool for Case Study 2, work through and bounce ideas off your colleagues.

Here are our thoughts on the two 780G Case studies. Don’t fake it and look at our thoughts first! Put in the graft, then cross reference. I bet you pick up novel things we missed!

Top Three Learnings:

Optimise time in range with a short Active Insulin time (2 to 2.5 hours) and tight Target (5.5 mmol/L). But, be careful for those with erratic activity patterns or lots of activity. Aggressive auto corrections lead to a lot of insulin on board, which can be problematic when mixed with sporadic and frequent activity.
Managing exercise and alcohol activities with Temp target is essential.
Regularly updating manual basal rates and correction factors in case of manual mode.

Session 4: CamAPS FX

You will need the AID Tool and the Survive and Thrive Guide for CamAPS FX, and if you have an Android phone please download the Amazon APP, then the CamAPS FX APP.

Full disclosure: this is the AID System we have the least experience with.

System Exploration and Data Analysis
Practical Case Studies and AID Tool Utilisation

Now it’s your turn.

Case Study 1, the AID Tool for Case Study 1, work through and bounce ideas off your colleagues.

Case Study 2, the AID Tool for Case Study 2, work through and bounce ideas off your colleagues.

Here are our thoughts on the two CamAPS Fx Case Studies. Don’t skip the real learning and look at our thoughts first! Learning happens through sacrifice. I bet you pick up loads of things we missed!

Top Three Learnings:

Adapting target levels for varying intra-day insulin requirements – the range starts at 4.4 mmol/L and goes as high as 11.0 mmol/L. Ultimate flexibility!
Using “Add meal” functions better manage hypos and high-fat meals.
The impact of inaccurate carb counting on algorithm efficiency. The more accurate the count, the better the algorithm works.

Section 3: Specialised Insights

Session 1: Nutritional Wisdom with Francesca Annan

Expert advice on meeting the basics first, balanced meals, carb counting, and pre-meal bolusing.
Francesca’s seasoned perspective and experience in knowing your systems and patients are immense!

Top Three Learnings:

Major in the Major! Ensure adequate energy and carbs first; these kids have gotta grow and thrive, not starve and survive. Structured days, balanced meals, and pre-meal bolusing remain the cornerstones for an optimal time in range.
Minor in the Minor. Navigating high-fat and protein meals with AID systems – FIND OUT BEFORE YOU FIDDLE! (I love this). Don’t overcomplicate until a problem arises. The algorithm may cope just fine!
The art of individualising advice for successful outcomes – meet the person where they are at, know your AID Systems, and learn through trial and error.

Session 2: Exercise Strategies with Dessi Zahareiva

Dessi’s amalgamation of research, clinical, and educational expertise is AMAZING.

This talk is about exercise and the four AID Systems is all killer, with no filler

Top Three Learnings:

Get Activity mode started 1-2 hours before exercise and consider reducing carbs entered into the bolus calculator by ~25% if eating 1-2 hours before exercise.
The Omnipod 5 will work underwater if the sensor and Pod are very close together!
After exercise, be ready to replace insulin quickly. Prolonged insulin suspension caused by activity mode results in glucose explosions following the after-exercise meal. There are lots of AID System-specific ways to prevent this.

I also share my thoughts on exercise and AID Systems. This long presentation (40 minutes) is not the same caliber as Dessi’s. However, it may hold some value for the nerdy ones;

The first 10 minutes tell you why exercise is the best longevity drug.
The following 15 minutes walk you through the risk factors for hypoglycemia during exercise in order of importance.
The final 20-minutes talk through AID case studies that include using open loop mode during exercise, and watch-outs for getting drunk after team sports when using an AID System.

Top Three Learnings:

AID and exercise: Rethinking traditional strategies, moving to T25/T25 as a starting point, but being ready to adapt quickly.
Large carbohydrate intakes immediately before exercise risk insulin being driven in by the algorithms during exercise, leading to hypoglycemia. Instead, drip-feeding fast-acting carbs in smaller amounts every 20-30 minutes is the winner.
Going back to manual/open loop mode 90 minutes before exercise ensures consistency in insulin conditions and reproducible glucose behaviour during exercise. This should be considered for athletes who want optimal performance and confidence in how the glucose will behave. Certainly not required for all, as it requires up-to-date basal rates and plenty of trial and error.

Session 3: Young Children and AID with Elizabeth Jelleryd

Elizabeth’s practical approach to managing T1D in young children is AWESOME!
Learning from her experiences and PhD mentorship with the T1D Legend “Dr. Carmel Smart”

Top Three Learnings:

Pre-meal insulin of at least 30%, but as much as possible, is necessary to prevent post-meal hypers.
Managing sporadic activities by consuming extra carbs is very much needed in young children using AID therapy.
There is a double benefit of structured meals that are balanced for kids with T1D.

Session 3: Thriving with AID and Managing Alcohol

Theory-driven insights and anecdotal experiences, mixed with emerging evidence
Practical tips for managing alcohol intake.

Top Three Learnings:

Don’t forget the basics. CGM and pump fundamentals are essential to ensure accurate CGM readings and healthy sites for consistent insulin absorption.
Strategic target adjustments overnight can prevent inconsistent post-breakfast spikes.
Use activity mode for alcohol management. Bespoke plans can be made if you know how each AID System reduces insulin. We may need to use manual mode if alcoholic drinks with carbs induce high glucose, causing the algorithm to go into overdrive. Above all, safety comes first, and have followers when drinking the booze.

Concluding Thoughts

You’ve now journeyed through the essence of AID therapy.

Ready to test your knowledge?

Dive into our Google Form quiz and see how much you’ve grasped!

Did you score 10 out of 10?

It’s time to move from conscious incompetence to conscious competence.

Go forth to practice, apply trial and error, and get your skin in the game!

If you enjoyed the programme please pay it forward and pass it on. Or, use the materials to improve it and deliver it to your team. If so, purchase an Adobe Acrobat Pro license and see how easy it is to customise all the PDFs.

Cheers

John Pemberton RD summarising for the BCH Team.

T1D since 2008

Dad to Grace and Jude for whom this blog is written – Read this

References

1. Phillip M, Nimri R, Bergenstal RM, Barnard-Kelly K, Danne T, Hovorka R, et al. Consensus Recommendations for the Use of Automated Insulin Delivery (AID) Technologies in Clinical Practice. Endocr Rev. 2023 Sep 6;44(2):254–80.

2. Griffin TP, Gallen G, Hartnell S, Crabtree T, Holloway M, Gibb FW, et al. UK’s Association of British Clinical Diabetologist’s Diabetes Technology Network (ABCD-DTN): Best practice guide for hybrid closed-loop therapy. Diabet Med. 2023 Jul 1;40(7):e15078.

3. Adolfsson P, Taplin CE, Zaharieva DP, Pemberton J, Davis EA, Riddell MC, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Exercise in children and adolescents with diabetes. Pediatr Diabetes. 2022 Dec 1;23(8):1341–72.

4. Zaharieva DP, Morrison D, Paldus B, Lal RA, Buckingham BA, O’Neal DN. Practical Aspects and Exercise Safety Benefits of Automated Insulin Delivery Systems in Type 1 Diabetes. Diabetes Spectr. 2023 Mar 1;36(2):127–36.

5. Pemberton JS, Kershaw M, Dias R, Idkowiak J, Mohamed Z, Saraff V, et al. DYNAMIC: Dynamic glucose management strategies delivered through a structured education program improves time in range in a socioeconomically deprived cohort of children and young people with type 1 diabetes with a history of hypoglycemia. Pediatr Diabetes. 2021 Nov 17;22(2):249–60.

6. Pemberton JS, Barrett TG, Dias RP, Kershaw M, Krone R, Uday S. An effective and cost-saving structured education program teaching dynamic glucose management strategies to a socio-economically deprived cohort with type 1 diabetes in a VIRTUAL setting. Pediatr Diabetes. 2022 Jun 11;23(7):1045–56.

7. Pemberton JS, Gupta A, Lau GM, Dickinson I, Iyer PV, Uday S. Integrating Physical Activity Strategies to Lower Hyperglycaemia in Structured Education Programmes for Children and Young People with Type 1 Diabetes Improves Glycaemic Control without Augmenting the Risk of Hypoglycaemia. Smart CE, editor. Pediatr Diabetes. 2023 Jul 5;2023:1–8.

8. Pemberton JS, Collins L, Sands D. Oral Abstract 67: Virtual schools training package teaches 37% more staff and reduces the cost by 83% compared to face-to-face training during the COVID-19 pandemic. Pediatr Diabetes. 2022 Oct 1;23:3–43.

9. Sherr JL, Schoelwer M, Dos Santos TJ, Reddy L, Biester T, Galderisi A, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes technologies: Insulin delivery. Pediatr Diabetes. 2022 Dec 1;23(8):1406–31.

10. Hanas R, Adolfsson P. Bolus Calculator Settings in Well-Controlled Prepubertal Children Using Insulin Pumps Are Characterized by Low Insulin to Carbohydrate Ratios and Short Duration of Insulin Action Time. J Diabetes Sci Technol. 2017 Mar 1;11(2):247.